NSG 3160 EXAM 3
HEALTH ASSESSMENT
ACTUAL QUESTIONS & ANSWERS /2026-2027
1. Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:
A. The spinous process of C7.
B. The spinous process of T1.
C. The transverse process of C7.
D. The spinous process of C6.
Correct Answer: A. The spinous process of C7.
Expert Rationale: The vertebra prominens is the prominent spinous process of the seventh cervical
vertebra (C7), which can usually be easily palpated at the base of the neck. It serves as an important
anatomical landmark during physical examination.
2. When performing a respiratory assessment on a patient, the nurse notices a costal angle of
approximately 90 degrees. This characteristic is:
A. A normal finding in a healthy adult.
B. A finding indicating severe pulmonary disease.
C. A finding associated with a barrel chest.
D. A finding indicating significant respiratory obstruction.
Correct Answer: A. A normal finding in a healthy adult.
,Expert Rationale: A costal angle of approximately 90 degrees is considered normal in a healthy adult.
Changes such as a markedly increased angle may indicate alterations in chest configuration associated
with conditions such as chronic hyperinflation.
3. When assessing a patient's lungs, the nurse recalls that the left lung:
A. Consists of two lobes.
B. Consists of three lobes.
C. Has four lobes.
D. Has no lingula.
Correct Answer: A. Consists of two lobes.
Expert Rationale: The left lung has two lobes—the upper and lower lobes—and contains a cardiac notch
and lingula to accommodate the heart. The right lung has three lobes.
4. Which statement about the apices of the lungs is true? The apices of the lungs:
A. Extend 3 to 4 cm above the inner third of the clavicles.
B. End at the level of the fourth rib.
C. Extend only to the first intercostal space.
D. Are located entirely below the clavicles.
Correct Answer: A. Extend 3 to 4 cm above the inner third of the clavicles.
Expert Rationale: The apices of the lungs extend approximately 3–4 cm above the medial or inner third
of the clavicles. This anatomical location is important when inspecting, palpating, and percussing the
upper lung fields.
5. During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates
anteriorly at the:
A. Sternal angle.
,B. Xiphoid process.
C. Clavicle.
D. Costal margin.
Correct Answer: A. Sternal angle.
Expert Rationale: The trachea bifurcates into the right and left main bronchi at approximately the level
of the sternal angle, corresponding to the T4–T5 vertebral level. The sternal angle is therefore an
important landmark during thoracic assessment.
6. During an assessment, the nurse knows that expected assessment findings in the normal adult lung
include the presence of:
A. Muffled voice sounds and symmetric tactile fremitus.
B. Bronchophony and increased tactile fremitus.
C. Egophony and absent tactile fremitus.
D. Whispered pectoriloquy and unilateral fremitus.
Correct Answer: A. Muffled voice sounds and symmetric tactile fremitus.
Expert Rationale: Normal lung tissue transmits voice sounds poorly, so spoken sounds are faint or
muffled. Tactile fremitus should be relatively symmetric over corresponding areas of the lungs.
Increased voice transmission or fremitus may suggest consolidation.
7. The primary muscles of respiration include the:
A. Diaphragm and intercostals.
B. Trapezius and sternocleidomastoid.
C. Pectoralis major and deltoid.
D. Rectus abdominis and latissimus dorsi.
, Correct Answer: A. Diaphragm and intercostals.
Expert Rationale: The diaphragm is the major muscle responsible for inspiration, while the intercostal
muscles assist with expansion and contraction of the thoracic cage during breathing.
8. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of being
awakened from sleep with shortness of breath. Which action by the nurse is most appropriate?
A. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea.
B. Documenting the finding as an expected effect of aging.
C. Encouraging the patient to increase fluid intake.
D. Asking the patient to lie completely flat during assessment.
Correct Answer: A. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea.
Expert Rationale: Awakening from sleep with shortness of breath is characteristic of paroxysmal
nocturnal dyspnea (PND), which commonly occurs with heart failure. The nurse should assess for
associated manifestations such as orthopnea, edema, and other evidence of fluid overload.
9. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most
intensely over which location?
A. Between the scapulae.
B. Over the lower abdomen.
C. Over the sternum only.
D. Over the clavicles only.
Correct Answer: A. Between the scapulae.
Expert Rationale: Tactile fremitus is produced by vibrations transmitted through the bronchopulmonary
system. It is normally more prominent over areas where the major bronchi are relatively close to the
chest wall, particularly between the scapulae.
HEALTH ASSESSMENT
ACTUAL QUESTIONS & ANSWERS /2026-2027
1. Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:
A. The spinous process of C7.
B. The spinous process of T1.
C. The transverse process of C7.
D. The spinous process of C6.
Correct Answer: A. The spinous process of C7.
Expert Rationale: The vertebra prominens is the prominent spinous process of the seventh cervical
vertebra (C7), which can usually be easily palpated at the base of the neck. It serves as an important
anatomical landmark during physical examination.
2. When performing a respiratory assessment on a patient, the nurse notices a costal angle of
approximately 90 degrees. This characteristic is:
A. A normal finding in a healthy adult.
B. A finding indicating severe pulmonary disease.
C. A finding associated with a barrel chest.
D. A finding indicating significant respiratory obstruction.
Correct Answer: A. A normal finding in a healthy adult.
,Expert Rationale: A costal angle of approximately 90 degrees is considered normal in a healthy adult.
Changes such as a markedly increased angle may indicate alterations in chest configuration associated
with conditions such as chronic hyperinflation.
3. When assessing a patient's lungs, the nurse recalls that the left lung:
A. Consists of two lobes.
B. Consists of three lobes.
C. Has four lobes.
D. Has no lingula.
Correct Answer: A. Consists of two lobes.
Expert Rationale: The left lung has two lobes—the upper and lower lobes—and contains a cardiac notch
and lingula to accommodate the heart. The right lung has three lobes.
4. Which statement about the apices of the lungs is true? The apices of the lungs:
A. Extend 3 to 4 cm above the inner third of the clavicles.
B. End at the level of the fourth rib.
C. Extend only to the first intercostal space.
D. Are located entirely below the clavicles.
Correct Answer: A. Extend 3 to 4 cm above the inner third of the clavicles.
Expert Rationale: The apices of the lungs extend approximately 3–4 cm above the medial or inner third
of the clavicles. This anatomical location is important when inspecting, palpating, and percussing the
upper lung fields.
5. During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates
anteriorly at the:
A. Sternal angle.
,B. Xiphoid process.
C. Clavicle.
D. Costal margin.
Correct Answer: A. Sternal angle.
Expert Rationale: The trachea bifurcates into the right and left main bronchi at approximately the level
of the sternal angle, corresponding to the T4–T5 vertebral level. The sternal angle is therefore an
important landmark during thoracic assessment.
6. During an assessment, the nurse knows that expected assessment findings in the normal adult lung
include the presence of:
A. Muffled voice sounds and symmetric tactile fremitus.
B. Bronchophony and increased tactile fremitus.
C. Egophony and absent tactile fremitus.
D. Whispered pectoriloquy and unilateral fremitus.
Correct Answer: A. Muffled voice sounds and symmetric tactile fremitus.
Expert Rationale: Normal lung tissue transmits voice sounds poorly, so spoken sounds are faint or
muffled. Tactile fremitus should be relatively symmetric over corresponding areas of the lungs.
Increased voice transmission or fremitus may suggest consolidation.
7. The primary muscles of respiration include the:
A. Diaphragm and intercostals.
B. Trapezius and sternocleidomastoid.
C. Pectoralis major and deltoid.
D. Rectus abdominis and latissimus dorsi.
, Correct Answer: A. Diaphragm and intercostals.
Expert Rationale: The diaphragm is the major muscle responsible for inspiration, while the intercostal
muscles assist with expansion and contraction of the thoracic cage during breathing.
8. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of being
awakened from sleep with shortness of breath. Which action by the nurse is most appropriate?
A. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea.
B. Documenting the finding as an expected effect of aging.
C. Encouraging the patient to increase fluid intake.
D. Asking the patient to lie completely flat during assessment.
Correct Answer: A. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea.
Expert Rationale: Awakening from sleep with shortness of breath is characteristic of paroxysmal
nocturnal dyspnea (PND), which commonly occurs with heart failure. The nurse should assess for
associated manifestations such as orthopnea, edema, and other evidence of fluid overload.
9. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most
intensely over which location?
A. Between the scapulae.
B. Over the lower abdomen.
C. Over the sternum only.
D. Over the clavicles only.
Correct Answer: A. Between the scapulae.
Expert Rationale: Tactile fremitus is produced by vibrations transmitted through the bronchopulmonary
system. It is normally more prominent over areas where the major bronchi are relatively close to the
chest wall, particularly between the scapulae.
